By M. David Soliven, LCSW, CASAC
Mental Health Counselor
GMHC
____________________________________________________________________________________
In the past five or six years, I was
privileged to be invited by several non-profit organizations and universities
to deliver cultural humility trainings and presentations about trans-gender
identities and experiences, and how to improve services to meet the
needs of the transgender community. As a Filipino, transgender man and a
clinical social worker, providing these trainings are personally and professionally
meaningful and important to me. I empathize with the struggles that the
transgender community face, with having their healthcare needs met, and I am
committed to supporting providers and agencies that truly meet the needs of
this community.
While in these presentations, I
tried to observe as many audience members’ facial reactions, gestures and body
language, as they are non-verbal forms of communication about an individual’s openness,
interest or defensiveness about an issue. Being observant of non-verbal language
also helps me identify how effectively I may or may not be communicating with
them. People’s level of knowledge, familiarity and skills, as well as beliefs and attitudes about the
transgender community, vary or overlap. Sadly, I have encountered many current
(as well as future) providers in the healthcare field who hold prejudice and
stereotypical beliefs and attitudes about transgender
individuals. However, because transgender women and men are highly stigmatized
and marginalized members of society and need an array of healthcare services, I
believe that it is incumbent upon providers to
learn information and to practice skills that treat transgender clients with
respect, sensitivity and dignity.
“Transgender” is an umbrella term to
describe persons whose gender identity do not match the sex that they were
assigned at birth. A transgender woman is an individual who was assigned male
at birth and
lives and/or identifies as a woman
or female. A transgender man is an individual who was assigned female at birth
and lives and/or identifies as a man or male. It is important to note that not
every person uses the word “transgender” to describe their gender identity.
Persons may also identify as “male” or “female.” Transgender people have a
range of choices when it comes to transitioning. Some may decide to transition
medically and/or socially, or not at all. Medical transition includes hormone
therapy, gender affirming surgery, chest or breast surgery, and electrolysis,
just to name a few. Social transition involves a legal name change, gender
marker change, disclosure of their transgender identity to others, change in presentation
(i.e., dress, hairstyle, etc.) and so on. Transitioning is a
personal choice and not every transgender person decides to do so. For many,
transitioning changes their lives in positive ways. For example, their anxiety,
depression, and isolation related to gender dysphoria might be alleviated. For others,
the costs and risks of transitioning are too high. They might jeopardize their
employment, housing, social relationships and status within their social
networks.
There have been significant gains
for transgender healthcare in the past few years. For example, Medicare and
several states’ Medicaid now cover medically necessary hormone therapy and
gender affirming surgery. Many provider agencies and organizations now provide
all-gender restrooms and have updated their program forms to include different
identities. Despite these achievements, transgender women and men continue to
face stigma, harassment and
discrimination in healthcare settings and social service agencies that include lack
of well-trained and informed providers, harassment in waiting rooms and
bathrooms and denial of services. Negative experiences contribute to avoidance
of healthcare services, poor medical and mental health conditions and distrust
of providers.
One glaring example of a healthcare services
gap is that transgender people are among the groups at highest risk for HIV and
AIDS. According to the Center for Disease Control and Prevention (CDC), “Among
the 3.3 million HIV testing events reported to the CDC in 2013, the highest
percentages of newly identified HIV-positive persons were among trans-gender
persons, and that Black/African-American transgender women were most likely to
test HIV positive, compared to those of other races/ethnicities: 56% of Black/African-American transgender women had positive HIV
test results compared to 17% of white or 16% of Hispanic/Latina transgender
women” (www.cdc.gov/hiv/group/gender/transgender/). The prevalence of HIV and
AIDS among transgender men have been reportedly low, but this might be due to
lack of research and understanding about their sexual behaviors and healthcare
needs.
Better anti-retroviral treatments
and pre-exposure prophylaxis, or PrEP, are available, and adherence to
treatment is vital to achieve and maintain an undetectable viral load and good
physical health. The effects of stigma and discrimination, however, can make it
difficult for trans-gender persons to be adherent to their medical care.
According to a study on the connection between treatment adherence and viral
load levels of transgender women of color, “Transgender women on ART were less
likely to report 90% adherence rates or higher and reported less confidence in
their abilities to integrate treatment regimens into their daily lives.
Transgender women reported
significantly fewer positive interactions with their health care providers.
Training for providers and integration of hormone therapy into HIV care is recommended”
(Sevelius JM, etal., Antiretroviral Therapy Adherence Among Transgender WomenLiving with HIV. The Journal of the Association of Nurses in AIDS Care, 2010).
Other factors also influence treatment adherence. Many transgender women may
prioritize: 1) hormone treatment because it affirms their gender identity, 2)
income-generating work (e.g., sex work,
part-time jobs, etc.) to support their living expenses, and 3) concerns about
the possible drug interactions between their hormone treatment and ARV
medications. More research needs to be funded and conducted about this issue in
order to gain a better understanding of factors that affect treatment
adherence.
Healthcare providers have a vital
role in improving the health outcomes of transgender people living with HIV and
AIDS. Stigma and discrimination serve as barriers and cause harm to transgender
clients who need HIV-related healthcare urgently. To serve this community, providers
need to prioritize the development of effective medical and social service interventions
that “not only address and improve health, but also promote health equity...” (Reisner, S.etal. GlobalHealth Burden and Needs of Transgender Populations: A Review,” The Lancet,2016).
Since 2012, I have worked proudly at Gay Men’s Health Crisis (GMHC) as a mental health counselor. GMHC is the nation’s
foremost advocate and leader in HIV and AIDS prevention, advocacy and comprehensive
care services. The agency exemplifies an organization that has taken seriously
the healthcare concerns of transgender clients and the professional development
needs of its staff. In 2014, GMHC established a committee whose primary purpose
is to meet programmatic needs and to improve the quality of life for transgender and gender
non-conforming individuals by developing and supporting a safe and
non-judgmental culture. To this end, orientations for new hires and regular staff
trainings include cultural humility trainings, two “All-Gender” restrooms are available,
agency forms are inclusive of different identities, and participation and collaboration
with community-based organizations at transgender-specific events have
increased. Additionally, there are several full-time staff who identify as transgender
and a support group for transgender people is led by a transgender woman of
color. The total number of transgender clients in 2015 was 68, and although this number is low
currently, this was an amazing increase compared to previous years. GMHC is
hopeful that the number of transgender individuals served by the agency will
multiply and obtain life-saving services and care.
The Collaborative Mental Health program
in which I work provides individual, couple and family counseling services as well
as support groups for long-term survivors, people in substance use recovery and
those newly diagnosed with HIV. In the coming months, GMHC will open an Article
31 mental health clinic licensed by the New York State Office of Mental Health
(OMH) and an Article 32 substance use treatment program licensed by the Office
of Alcoholism and Substance Abuse Services (OASAS). Because the transgender
community face a high risk of mental health conditions and substance use, often
as a consequence of stigma and discrimination, the expansion of services designed
specifically to address these issues attest to GMHC’s commitment to the healthcare
needs of transgender people.
Finally, cultural humility skills
and practices do effect positive changes. Skills and practices that can help
providers include, but are not limited to, the following list:
• Understand basic terms,
definitions and health risks;
• Use appropriate gender pronouns
and names;
• Discuss hormone, PrEP and ARV
treatments with clients;
• Provide safe bathrooms;
• Arrange regular staff trainings
about transgender health issues;
• Collect accurate demographic data;
• Employ transgender staff in all
levels of the agency;
• Team up with community partners to
advocate for housing, jobs, and healthcare; and,
• Understand the interconnections
among stigma, discrimination, misinformation, and poor health outcomes
(New York State Department ofHealth, Care of the HIV-infected transgender patient, 2012; Center of Excellence
for Transgender Health, 8 best practices for HIV prevention among trans people,
http://transhealth.ucsf.edu; National LGBT Health Education Center, Affirmative
care for transgender and gender non-conforming people: Best practices for frontline
health care staff, February 2013; San Francisco Dept. of Public Health, Transgender
HIV/AIDS health services best practices guidelines, July 2007).
When transgender clients feel welcomed
and are treated with respect, sensitivity and dignity, their engagement in treatment
and their investment in their health can improve. Establishing cultural humility
skills and practices may involve hurdles and challenges, but the outcome can
increase access and retention to care. Stigma and discrimination can no longer have
a place in healthcare.
If you are interested in learning
more about GMHC’s programs and services described above, please visit
www.gmhc.org or call (212) 367-1000
Read more articles here: Behavioral Health News
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